When can an athlete return to training after a concussion?

1.

Taylor, Alex M., Meehan, William P., Proctor, Mark R. (2025). Sports-Related Traumatic Brain Injury (Concussion). In Nelson Textbook of Pediatrics (pp. 4314). DOI: 10.1016/B978-0-323-88305-4.00729-X

There is a six-stage return-to-play (RTP) protocol for a safe return to activities (seeTable 729.2). Starting with physical rest, athletes are progressed to light aerobic exercise, moderate levels of sport-specific exercise, noncontact training drills, full contact practice, and normal game play. Athletes should be completely asymptomatic, free of medications used to treat concussion symptoms, at full school, and back to baseline functioning on all domains tested before the injury before returning to contact or collision sports. Children and adolescents should remain at each stage of rehabilitation for no less than 24 hours before advancing to the next level. Thus a minimum of 5 days should pass before consideration of full return to competition. If symptoms return at any stage of exertion, the athlete should rest until the symptoms resolve and then return to the previous level of exertion. The final decision for RTP should be made by a licensed clinical provider with experience in the evaluation and management of sports-related concussions. Note that some states or schools require an extended minimum number of symptom-free days before RTP, so clinicians need to be aware of the laws or local recommendations regarding RTP.

2.

Elsevier ClinicalKey Derived Clinical Overview

• Physiologic recovery is slower than symptomatic recovery. Protocols involving a symptom-free waiting period before return to play are warranted.Table 4summarizes recommendations on returning to play after a concussion. CDC protocols for managing return to activities after concussionare described inTable 5. Physical and cognitive rest are the cornerstones of initial concussion management, with subsequent gradual return to school and physical activities. Repeated concussions, especially within days or weeks, carry a significant risk of permanent brain injury (second impact syndrome). • If concussion symptoms occur with activity at one level, the athlete should stop the activity, rest until symptoms resolve, and then restart his or her progression at the level that did not elicit symptoms. • There are no evidence-based guidelines for disqualifying or retiring an athlete from sport after a concussion. Each case should be individually considered.

3.

Elsevier ClinicalKey Clinical Overview

Special Considerations Patients may report history of earlier sports-related head injury or concussion, or review of systems may find concussionlike symptoms. In this scenario, a complete neurologic examination should be performed Athletes with ongoing signs and symptoms of concussion should not be cleared for participation until all symptoms have resolved Concussion symptoms include: Headache Dizziness Nausea or vomiting Difficulty concentrating Fatigue or sleepiness Slurred speech Blurred or double vision Confusion Because many teens may report these symptoms even without concussion, consider using validated tools such as the SCAT (Sport Concussion Assessment Tool) to establish a baseline in patients at higher risk of concussion injury. SCAT-5 Neuroimaging is not indicated unless intracranial bleeding, serious brain injury, and/or cervical spinal injury is suspected or cannot be ruled out; concussion symptoms are not caused by macroscopic neural damage but rather by disturbances in neurochemical pathways at the cellular level A second injury before the brain has fully recovered results in worsening of the cellular metabolic changes and decrease in cognitive function Second impact syndrome Rare condition in which athletes sustain a second head injury before symptoms of the initial concussion have fully resolved Mortality rate is nearly 50% and morbidity rate is nearly 100%; this emphasizes the importance of allowing the brain to fully heal before return to the activity that caused the initial concussion Athletes are considered clinically recovered when asymptomatic at rest and able to participate in usual activities without symptoms, including school, work, and sports Expected time frame to recover from a concussion is 2 weeks in adults and 4 weeks in children The baseline comparison method, in which an athlete’s postconcussion performance is compared with a healthy baseline evaluation from before the athletic season, has been described as the gold standard in concussion management by some experts Several tools have been suggested as adjuncts to the SPE, including: Baseline computerized neurocognitive testing Child and adult SCAT-5 (Sport Concussion Assessment Tool, fifth edition) Graded symptom checklists Balance Error Scoring System Tandem gait King-Devick test Vestibular Ocular Motor Screening